HomeMy WebLinkAbout024-741-20-4112-SAN-2023-209 ,-°'`� Department of Safety c°°" / �
_ � � = & Professional Services �� Z
- �. �� _ � Sanitary Permit Nu �er(to be filled in by(
s _ Industry Services Division �
(� � � �O� q�
,. . �
Sanitary Permit Application s`a`eT�°�°`;°"N°"'be� ,
ln accordance with SNS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemmental unii �- �
is required prior to obtaining a sanitary permit.Note:Application forms for state-0wncd POWTS are submitted to Project Address(if different than mailing ad �
the Department of Satety and Pmfessional Services.Personal information you provide may be used for secondary �
purposes in accordancc with the Privacy Law,s. 15.04(1)(m),Stats. �
I.Application Information-Please Print All Information
Properiy Owner's Name e Parcel tt ��� /����'������
�. � �e rV1, �-�-F� -�
PropeRy Own Mailing Address Property Location
V Govt.Lot
Cit , tatc Zip Code Phone Number
�/��l✓�I t � U ��/'� ��4,�C����, SeCIl017 �—
���,�.�� �,
II.Type of Building(check all that apply) Lot#� T �� N R � E or
�] 1 or 2 Family Dwelling-Number ofBedrooms � Subdivision Name
Block#
❑Public/Commercial-Describe Use
❑City of
❑State Owned-Descri6e Use CSM umber � ❑Village of
��i��l 5$S3 �c,�„�of_��d �-� —
Iii.Type of POWTS Permit:(Check either"New"or uReplacement"and other applicable on line A. Check one box on line B.Complete line C if
a licable.)
A.
❑ New System �Replacement System ❑ Other Modification to Existing System(explain) ❑ Additional Yretreatment Unit(explain)
B' ❑ Holdin Tank � In-Ground ❑ At-Grade
g ❑ Mound ❑ lndividual Site Design ❑ Other Type(eKplain)
(conventional)
C• ❑ Renewal Before ❑ Revision ❑ Change of Plumber ❑ Transfer to New Owner ist Previous Permit Number and Date Issued
F,xpiration 9 I - ��g � la I\9 �l
N.Dispersal/Treatment Area and Tank Informallon:
Design Flow(gpd) Design Soil Application Rate(gpd/s� Dispersal Area Required(s� Dispersai Area Proposed(s� System Elevation � ���� (
3c�o • 7 Y £� o ,
Capacity in Tota #of Manufacturer
�
Tank Information Ga]]ons Gallons Units p � v '$ � � u
New Tanks f:xistine Tanks � o � L � p � �y
a. U �n � v� i�. C7 Li
� �
Scptic or Holding Tank � � 7�-� > Gv��� �, �
/
Dosing Chamber
V.Responsibility Statement- I,the undersigned,assume responsibility for installadon of the POWTS shown on the attached plans.
Plumber's Name(Print) Plumbe 's Signamre MP/MPRS Number 6usiness Phone Number
�9 0 l ��s-ss-�s-b�.3
umber s Address(Street,City,State,Zip Code) �
05� l�l � a,r�� �a� u� S��SG3
VI.Coun y/Department Use Only
�A o��d ❑Disappro�ed $t�it Hee� Datc Issued Issuing Agent Signawre
��> ❑Owner Given Reawn for penial ��� ��3� I a 3 �rv�.��,e,���,�,,,�--
Conditions o�pproval/Reasons for Disapproval
, ��,� �aa�e__�_�_31�.-�3.__.._.___ �._ � � � ���
�� ��GI ��,
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'--;►,k# a�,�--- AUG 2 8 2Q23
CS� �-3 -- i3 �� a�« -
s�,wYCr� co«raTv
hING ADMINISTRATiGtJ
Attach to complete plans for the system and submit to the County ooly on paper not less thao 8 1/2 x 11 inches in size � r� ..'�
NO RCFtJNa�AFTER
ssr�-639a�x.o3i22� ISSJE OF P'ER�'ll
nn n�\
PAGE 1 OF 4
In-Ground Gravity Plan
Index & Cover Sheet
Componenf Manual Design References:
In-Ground Soil Absorption for POWTS Version 2.1 (May 2022-2027)
Pg 1 of 4 Index & Cover Sheet
Pg 2 of 4 Plot Plan
Pg 3 of 4 Dispersal Area Cross-Section & Plan View
Pg 4 of 4 Management Plan
Attachments: Enclosures:
POWTS Application for Review
Soil Evaluation Report & Site Map
Project Name / Description
Owner Name(s): ,�,ri�U L. � S(�.( { YYI�• C'I''� Phone: - -
Owner Address: �(��y� �, Tt C��� • � �(,(�ZiP: J`����
Project Address: ��F
Govt. Lot: �F 1/4 of S(.� 1/4, Section_�, T �� N-R�E Q or W�
Township: �'�1�rt�C.�.. ��Q,.� County: ���l,GU A,�./�
Project Parcel ID #: �� ��� �a �l o�
Designer Information
Designer Name:��J�1/1 Phone: - -
Designer Address:� � ZiP= 5�
E-mail: (,l�l�l�r G2.��
License Number: ������ �
Remarks:
�., ------__ O �o`-� ��
Signature: ` Date:
riginal signature required on each submitted copy.
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j Septic Tank(s)Manufacturer;
� IN-�ROUNL� GRAV(TY C�I�F'ERS�eL At��A ����� � /dr � ,� ,� r�/�.-�;
U niforrn �lev�tion Trenches with Quick4 �tand�rd�W Chamb�rs Saptla T'ank(s)Valume(s):
3^ft Trench (dawn-sizing c�e�ifi) �?� g�� ,�_ ga� .,�,. ea� ��a�
Eftluent Filt r Manufacturer;
..,�,?f�'�� �i �L.1 —f'c/�i�
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� � - min.12" Effluent Fliter Madei i�; ,��,�„ �f„'1�,�,,,,�,���
SOIL COVER (lYpice►)
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min.Irvnch
daplh
�`�P'°°'� _ �'� 4�' TYPICAL TRENCH
' ' � '° ' � '''��a 'a CROSS SECTIC7N VIEW
�. � � ' ,, , �
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(typ c01)� �;�4' ,, , . (No Scale)
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• � i'rovide minimum 3 ft
System �levation =��� ft soparation bokween trenches,
(typical)
Qulck4 Standard-W
w/�nd Cap (5how Iocatlon of Inlet/outlet nipe connaction on plan v(ow.) �bee�y�lcal) Ip� TYPICAL TF�ENCH
(typlcal)
Insteii per manufacwrore PLAN VI EW
Instrucqons.
(No Scale)
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(typlcal) Qulcic4 St�ndard-W Chamber t�
INSTAL.I� P�R TRENCH; ttyptoa�) a
(mfd by(nflltrator Systems,►na,) .T.'
Z Install pursuant ta menufaalurers(netructions, �
' Quick4 5td-W @ 20 f�EISA/chamber= ,2Z�..1e ft
+ �.,�, f�airs of end caps @ 6 ft2 EISA/pair� __� ' , ft�
= Proposed E15A ner trench = � ffiz Requlred Inflitratlon Area� �,�, ftz Disfiribution Method:
x ,^�,,,, , trenches = Propased Total EISA � � ftz �✓eq�,��.,��� ' �
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PAGE40F4
In-ground Gravity Management Plan
IMPORTANT:
The owner of this in-ground gravity system shail be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384,Wisc.Admin.Code. Pursuant to SPS 383.52(2),Wisc.Admin,Code,this system shail
be considered a human health hazard if not maintained in accordance with this approved management plan.
Furthermore,all inspection and maintenance activities shall be perfortned by a registered POWTS Maintainer in
accordance with SPS 383.52(3),Wisc.Admin.Code.
Maximum Disaersal Area O�eratinq Limits:
Design Flow= 3f�� gpd; BODS 5 220 mgL''; TSS 5150 mgL"'; FOG 5 30 mgL"'
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use
o age of system
o nuisance factors(i.e.odors,user complaints,etc.)
o mechanical malfunction(i.e.,pumps,valves,switches,floats,etc.)
o material fatlgue(i.e.,leaks,breaks,corrosion,etc.)
o solids volume in anaerobic treatment tank(s)and any distribution appurtenance(s)(i.e.,distribution/drop boxes)
o neglect or improper use(i.e.,exceeding design capacities,prohibited activities,etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities-if applicable(i.e.,pump re-cycling,float switch settings,etc.)
o electrical components-if applicable(i.e.,wiring,connections,switches,controls,timers,alarms,etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure-compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS(or when necessary)
0 3eptic and dose tank(s)shall be pumped by a certified septage servicing operator licensed under s.281.48 Wis.
Stats.when the volume of solids in the tank(s)exceeds one-third(1/3)the liquid volume of the tank(s)or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113,Wisc.Admin.Code.
o Effluent filter(s1 shali be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
System maintenance reports shall be submitted to the proper local government unit in accordance with
SPS 383.55 Wisc.Admin.Code. Report any component failure or malfunction to:
Name of individual or company:�U�t� -�Y� Phone:������5��
Local government unit: Phone: ���1�0,3������
Local government unit address�U Q Ll� ZIP: 5�7�5 'c� _
Any defective part of this system shall be repaired,replaced,or removed pursuant to SPS 383.51(1),Wisc.Admin.
Code.Repair or replacement of failed or malfunctioning components shall comply with SPS 383,Wisc.Admin.Code.
No product for chemical or physical restoration of the POWTS may be used unless approved by the department in
accordance with SPS 384,Wisc.Admin.Code.
Continqencv Plan
In the event that any failed treatment component of this POWTS cannot be repaired,it shall be replaced pursuant to
a plan submitted to the appropriate agency for review and approval. A failed in-ground dispersal component may be
abandoned and replaced by a code-complying dispersal component in a pre-determined area of suitable soils.
Svstem Abandonment
If use of this POWTS is discontinued,it shali be abandoned in accordance with SPS 383.33,Wisc.Admin.Code.
___
` '�"" ,, PRIVATE ONSITE WASTE TREATMENT county
=, � o \ SYSTEMS
'�.�SPS ( POWTS) Sawyer
A�>�'.y.-r�i:,
INSPECTION REPORT Sanitary Permit No:
Safety and Buildings Division (ATTACH TO PERMIT)
GENERAL INFORMATION �,3 —oZQ�
Personal infonnation you provide may be used for secondary purposes[Privacy Law,s. 15.04(I)(m)]
Permit Holder's Name: ❑City ❑ Village Town of: State Plan Transaction ID#:
I.C.�•r �-�-�1��. C�4— ���� C.,I�c� �
Insp BM Elev: BM Description: Parcel Tax No:
(oa . o ` �a�w, � �s.-�, o� al�. 11;� o�K-7Y(-2d-Ylr-�
TANK INFORMATION ELEVATION DATA r;
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV
Septic •�- S ��C Benchmark �op,p�
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet yb.o '
TANK TO P/L WELL BLDG VENTTO ROAD �ttntet- ('�
AIRINTAKE �1 � $p.9 '
Septic NA � a� $�,g �
Dosing NA Installation
Contour
Aeration NA Header/Man. �
Holding Dist. Pipe
PUMP 151PHON INFORMATION Surface e 8�•6�
Manufacturer Demand Final Grade
Model Number GPM
TDH Lift Friction Loss Sys Head TDH Ft
Forcemain L Dia Dist.To Well
DISPERSAL CELL INFOR ATION
DIMENSIONS �N 3 L c� c{ #of Cells Type of System Distribution Media Manufacturer:
SETBACK OHWM of Nav � Conv ❑ Aggregate � � � .
INFORMATION P/L Bldg Well �/yaters � IGP �G Chamber
❑ AG o EZFIow Model Number:
❑ Mound o Other
CELL TO .E-o1..'r —�3 - '�Sa —�D --- -- __ --- —_ �`►'� __ _
DISTRIBUTION SYSTEM x Pressure Systems Only
g g PO — --- P - 1- . - X Ho�le Observation Pipes '
[ Len�{hr/Manrfold Dia �L�enribution Pi e s Dia S ac �' Spacing ❑Yes ❑ No _ ',
� X Hole Size
SOIL COVER
- -- - -
Depth Over Depth Over Depth of � Seeded/Sodded � Mulched �
Ceil Center Cell Edges , Topsoil ❑Yes ❑ No ❑Yes ❑ fvo
COMMENTS: (Include code discrepancies, persons present, etc.)
��l(� ��� ��3
p � , 03 �� �� ; �--_�, _ ____� ��� �� �
Plan revision re uired.�Yes 0 No ` '
Use other side for atlditional information Date POWTS Inspector's Signature Certification Number
SBD-6710(R.3/01)
AODITIONAL COMMENTS AN� SKETCH
SANITAAY PERMIT NIJMBEA ______ oL 3=���
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